oh my, :(
thank you for posting these demo pictures, a ways back, of the
rubber pieces and the loops and metal clips, (don't know the tech word)
and HOW they fit... i did not understand how this set-up was not seen, or done right, etc... now i see...

:(

i am a mommy and gramma, so i hope, in this sense, it is okay to share this--though i do not know of the 'physical body' part of climbing:

i DO know about the brain, though, and how it can 'play tricks' at times,
something you can 'think' you see what you should see, IF your brain is
in READY position for a new chore (the habit feature that kicks in) THAT
is why our 'knowledge, skill, practice, and precaution' area of the brain
NEEDS to be honed, and then LISTENED to...

i have a problem with 'transposing' (flipping opposites, or combos of yes/no pairs, IF i am in a hurry) so i understand how VERY VERY SERIOUS it is to CHECK AND RECHECK even if we 'feel silly' or others think we are 'weird' or over-reacting, :(

i am so very sorry to see what the 'closer look' at this situation WAS, :o

i can also see how a young child (if they did look at their gear fast) may not even have noticed--the brain 'trick' (optical illusions, as well, as to certain pictures, it sees, that are similar to other pictures) :(

we MUST teach kids to check and recheck and EVALUATE EXACTLY what it is that they ARE seeing or ARE NOT seeing... then--it will click into the brain, faster than a GLANCE...

of course, this goes for OLDER climbers as well, as, it is not
fully comprehended yet, to older folks but:

YOUR eyes and brain DO register DIFFERENT as well, when you age, you MAY
run on HABIT MORE and think things are okay...

also, things are not deciphered right, due to 'far-sightedness' ...
and depth perception changes... you may THINK something is tied on,
from a distance WHEN in fact, it is not, :O

once again, my deep condolences to the family, and my on-going prayers for the father and all concerned... this was so awful, :(

please, i usually do not post such things in sad thread like this ( i did once, long ago, and it was a boo boo, when i first came here) but:

in this case, DUE TO seeing and reading what THE BEAUTIFUL BRAIN CAN DO, and how it can TRICK us, as wonderful as it is:

i just HAD to share this info... our brain gets on 'auto pilot' at times, and, sometimes we NEED to CONTINUAL set it on NEW IMMEDIATE 'ALERTS'...

climbing, as all we do, is really brainwork, first and foremost,
at the foundation--hone this brainwork...

OTHERTIMES, TOO, it can block out things that it has reckoned
'are not part of the moment at hand':
ex: things LOOK well, therefore, they are...
(processing is a SERIOUS ISSUE of before, during and after CONNECTIONS, along with covering the 'what ifs')

:(

as you are all climbers that i love, may any, some, or all, of this
BRAIN INFO, help folks, in some ways...

Of course, setting up the draws in that wrong configuration is an incredibly stupid error to have made, obviously one born of inexperience. It’s something I can’t possibly imagine anyone ever doing. Obviously the person who made this mistake looked at a properly racked draw, and tried to recreate what she or he saw. It was a horrible mistake. But it was also a freak mistake—something none of us could’ve ever predicted.

As we know, if the worst-case scenario can happen, the universe sometimes conspires to show us that it will.

This isn’t the first time a climber has died because of someone’s inexperience. And it won’t be the last. But this was an accident that could’ve happened to any of us, regardless of age, gender, experience.

I don't think an adult would have been nearly as likely to wrongly assemble the QD's--whoever did was not necessarily of low intelligence, but just someone who was completely ignorant about important aspects of the way the world works (rubber bands are not particularly strong; webbing used in climbing equipment is).
I have to think kids are far more likely to be ignorant, in ways that we won't be able to predict but which may have catastrophic consequences.
That's why they need more supervision and perhaps more detailed training, and we shouldn't disregard the youth of the people involved in this tragedy.

I completely disagree with that analysis. The accident was caused by human error and as such there are methodologies to follow that can limit the risk and prevent these occurences. The airline industry is a great example of how process improvment has saved countless lives.

In fact, this was the first day of Tito’s life that he went climbing outdoors without his father there

I agree with Port...this was a human error and not a equipment error. Hopefully these clubs/gyms will make it mandatory that all gear is check out by qualified adult/adults when taking these kid groups out.

Human error made easier by poorly-designed equipment. Surely on certain types of quick draws it is very difficult to get the biner through both the sling and rubber "keeper"--at least for someone as ham-handed as myself. I can see how someone, not only a child (but obviously more likely with someone young and/or inexperienced) could think they got the "nose" of the biner through the sling material when, in fact, they'd squeezed it between the sling material and the rubber. That is human error, sure, but one that could be less likely with either a better design (and, no, I don't have one)or by having the draws pre-assembled (though this doesn't solve the problem when one has to replace worn slings on still good biners). But a horrible and terribly sad tragedy whatever the cause.

I don't think an EXPERIENCED adult would have been nearly as likely...

If you have ever worked in a gear shop you know just how clueless inexperienced adults can be. And if you have ever read the stupidtaco, you know just how stupid some adults can be, even the "experienced" ones.

I suppose you might say it's poorly designed in retrospect, but I wouldn't really fault the manufacturer--I just don't think it would occur to anyone who has the slightest idea how climbing equipment works to set up the draws that way.
I don't see this as the assembler making a "mistake" in the sense of mis-threading something or forgetting to do a process step; she just didn't understand what the hell was going on at such a fundamental level that it would be hard for a designer to even contemplate that someone would do what she did.
It's like someone who thinks a harness gear loop will hold substantial force and tying into it--you can get a harness that guards against that with fortified gear loops, but I wouldn't say normal harnesses are "poorly designed."

Do those plastic holders really do anything? Do they make clipping that much easier? Or are they an unnecessary doo-dad bling accessory? Some dog bones I have seen have very tight loops and require a bit of effort to thread the biner. I ask because KISS matters.

At 12 years of age, Tito would have been starting middle school in September if he were local. He’d be four years shy of being able to drive a car. Lack of competent supervision – complacency – is the cause of his passing. So sad.

Those rubber keepers are not needed. Isn’t their purpose to keep the gate of the biner that gets clipped from wobbling? Just sew the dog bone loop tight so that it takes some effort to thread the biner. Done. The keepers are a gimmick – a solution looking for a problem. Am I missing something here?

Credit: Gene

[Note that the picture has the gizmo on the wrong end of the draw as was pointed out previously. My arrow should be at the other end of the draw.]

Why market a product that is not needed and is just another link in a chain of what could and did go wrong?